The QIDP

Tuesday, September 19, 2017

When ICF/IID programs deal with state issues, the three words that most hate to hear is "State is here." It's the sign that an investigation, complaint, or a survey is about to start. Usually none of those situations inspires any level of comfort. Most facilities dread getting the paperwork together, answering the questions, supplying the information needed, and dealing with the potential of deficient practice being cited. In Texas, once a health team shows up for survey, you can anticipate that Life Safety Code or LSC is not far behind. As a result of LSC, the program generally goes from a sigh of relief that the surveyors have left the building, to the feeling of "Here we go again" as the LSC rolls through the door. Suddenly there is an entirely new set of questions being thrown at the facility. You end up showing fire alarm permits, fire marshal inspection (not always easy to get in many parts of Texas by the way) and dealing with a variety of other questions. Everything suddenly shifts from the health, safety and well-being of the individuals living in the home, to the safety of the individuals from a view of the home being safe. LSC doesn't care whether the individuals have gone for annual vision exams or not, but they sure do care if you haven't gotten an inspection required for a part of the home.

Fortunately, I have found that the LSC survey can often be a vital and very important part of the survey process. While you may not always agree with their findings, you can always be sure their findings are an attempt to ensure the safety of individuals, staff and visitors to the home. During a survey recently, we found an example of how important having the second set of eyes of the LSC surveyor can be to the facility.

The survey had gone great with only a few minor LSC issues being pointed out. At the end of the survey, the surveyor asked for our Smoke Sensitivity Test. We talked about it and the surveyor said I could email it to him.

After a quick call to the alarm company, they sent the inspection paper and told us that there should be a blue tag in the alarm box with the sensitivity test information on it. We copied both and sent them to the survey team. Within a short time a call returned that indicated the paperwork we sent was not what they needed. They gave us specific information to look for from the fire alarm company.

Another call and clarification with the fire alarm company brought some "alarming" information to light. The fire alarm company stated that according to their records, they had never done a smoke sensitivity test of the system at the home. Needless to say we were shocked.

The end result was a deficiency for failure to have the smoke sensitivity test completed. However, the more important end result was that the process of the LSC survey had resulted in our facility finding that we did not have a smoke sensitivity test. It was an issue that could have easily put all individuals living in the home at risk, and a clear example of why LSC surveys have an important role in the ICF/IID program.

We have now looked at the first two parts of the POC which
you must include to have a successful and accepted POC by the state of
Texas.First you had to determine who
will fix the problem and how it is going to be addressed for the individual or individuals
affected by the deficient practice.The
second part of this series discussed how you are going to ensure the deficient practice
has not affected anyone else and who will accomplish that review or
process.At this point your plan
identifies the problem, identifies who was affected, identifies how you plan to
fix it, and identifies how you plan to review and ensure that anyone else
affected by the deficient issues does not continue to be affected.

Finally, it is time for the third step in the process of
preparing a successful POC.This final
step includes the monitoring of the issue and/or how you will ensure that the
deficient practice does not occur again.Usually at this time you find someone to oversee the person fixing the
problem.In most cases, you may have a
QIDP, a manager, or a nurse correcting the issue.For our sake, here we will assume the QIDP
has addressed the deficient practice.Who will oversee the QIDP and ensure that the problem does not occur
again?For many facilities the answer is
usually an Executive Director, Administrator, Owner, or some other form of
supervisor.This person must review the
correction made, and then set up a monitoring to ensure that it does not occur again.

In the first section, we stated that “The QIDP will conduct an interim staffing for
individual #1 to review the physician's recommendation for..... .an optional
surgery and determine the client and his guardian's decision. ..a specialist to
see the client. The QIDP will ensure the follow up appointment is
scheduled and coordinated with the IDT.

In the second section, we stated that “The QIDP will review physician recommendations
for individuals #2-6 (assuming it is a six bed facility) and ensure that no physician recommendations
have been overlooked. In the event that recommendations have been
overlooked, the QIDP will refer the recommendation to the IDTeam for review and
direction per the guardian, surrogate, or individual as appropriate.

Now we must ensure that the QIDP continues to monitor and that no physician
recommendations have been overlooked.We
must also ensure that someone is checking to ensure the QIDP completes this
function.A statement of correction
might look something like this:

The QIDP will review
Physician recommendations for individuals #1-6 on a monthly basis to ensure no recommendations
are overlooked.Issues or concerns will
be presented to the IDTeam.The
Administrator will review physician recommendations on a quarterly basis and
notify the QIDP in writing should a recommendation be found that has been
overlooked and take corrective action as determined appropriate.

At this point, you have now written all the major steps for the POC.You have accomplished the following:

1.Identified the individual or individuals
affected by the deficient practices, who will correct that issue, and how that
person will correct it.

2.Identified how the person correcting
the issue will ensure that no other individuals have been affected by the
deficient practices.

3.Identified how the facility will
continue to monitor and ensure that the deficient practice does not occur
again.

At this point you will put a corrective
date – meaning the date you plan to have the POC accomplished by and all components
in place, sign the document and submit it for review by the Regional Program
Manager.

You should be prepared for the possibility
that the Program Manager may seek additional information.There is always the chance you may have
overlooked a component of the deficient that needs to be addressed.There is always the chance that you may
understand perfectly what you plan is, but that it may not be written in a way
that someone else can understand it.If
additional information is requested, talk with the reviewer, determine what is
needed and provide the update.Some
regions will accept an update letter and others may require that you modify
your actual POC with the new information and send it in to them.However, it is requested, simply make the
corrections and send it in for final review.However, in most cases if you review the three major areas noted above,
and you have met the criteria of each, you will most likely not have to submit
additional information.

Saturday, January 7, 2017

In the first part of these installments, we discussed the fact that a POC must establish that in your plan you are going to fix the problem and who is going to address it and how they are going to address it. Since the first part of the POC describes the individuals directly affected, who is going to set the corrective action in motion and how that person will do it, it is time to move on to the next part.

The second component of a POC requires the facility to identify everyone who may be affected by the deficient practice and how the facility will ensure that the deficient practice does not occur to someone else. In simple terms, the survey team has usually looked at a sample of people. Let's say you have a six-bed facility and they look at three people. There are three other people who could have the same problem - even if surveyors only identified the problem for "One of three sampled individuals" this does not mean that individual number four might not have the same concerns or problems. All this means is that the survey team did not look at individual number four and he or she may have the same issues. To ensure that no individuals in the facility have the same issue or problem, the facility must identify how it is going to ensure the deficient practice does not affect others.

Thinking back to the last post, you will remember that the tag written was for failing to follow up on a physician's recommendation. The POC has set forth that the IDTeam will meet, make recommendations and the QIDP will implement those recommendations. The question at this point that must be considered is "Has the facility overlooked any other physician recommendations for anyone else residing in the facility?" To answer the question, the ICF must address how it is going to ensure that anyone potentially affected has been reviewed.

At this point the POC may state something like the following:

The QIDP will review physician recommendations for individuals #2-6 (assuming it is a six bed facility) and ensure that no physician recommendations have been overlooked. In the event that a recommendations has been overlooked, the QIDP will refer the recommendation to the IDTeam for review and direction per the guardian, surrogate, or individual as appropriate.
Based on the above statement, the POC now clearly indicates that the QIDP will be responsible to check and ensure that there are no other individuals in the home being affected by the deficient practice. Further, if an individual is being affected, the the plan indicates how it will be corrected.

For the third part of this series we will look at what must be done to ensure that the problem does not occur again. This part is usually considered the "monitoring" to ensure the problem is caught or does not happen again section of the POC. For our purposes it is the third part of a POC.

Sunday, December 4, 2016

If you are familiar with the ICF world, then you know exactly what the title of this article means. It means you have to write a POC or Plan of Correction for the program where you provide services. No program wants to see a set of deficient practice tags, but the fact is you're going to seem them more often than not. State surveyors are going to arrive, monitor your program and write tags from time-to-time. Those tags are going to show up on a form 2567 and you're going to have to write a POC to address each one.

Writing a POC is not always as easy as it looks. Most of us would like to simply write, "We made a mistake, we fixed it, we won't do it again," and be done with it. Unfortunately, the state, especially Texas, will not accept this time of POC. In fact, it can help to know that they are looking for specific things when you write your POC. There is no way this blog can address all the potential deficient practice you may face, but we can look at the specific criteria that, if met, should help you get your POC approved and your program moving along in the right direction.

The first thing your POC must do is establish that you are going to fix the problem and explain how and who is going to fix the problem. The state of Texas often views this as wanting to know how the corrections will be completed for the people identified as being immediately affected. You can not, for example, simply say the facility is going to fix the problem. You must be specific. Let's say, for consideration, that you received a deficient practice tag for failing to do review a physician's recommendation for client #1. In this case, your POC might start out something like below:The QIDP will conduct an interim staffing for individual #1 to review the physician's recommendation for.....

With the above you have started the POC off with who, the QIDP, will do what, an interim staffing. This may or may not be enough to satisfy the need of the POC. It all depends on what the physician's recommendation was and when it was made. For example, the physician might recommend an optional surgery. At that point the IDTeam would simply need to review the recommendation as stated and perhaps have the following statement:

.....an optional surgery and determine the client and his guardian's decision.

On the other hand the recommendation may be specific such as a referral for a specialist. That POC would be written as such:

....a specialist to see the client. The QIDP will ensure the follow up appointment is scheduled and coordinated with the IDT.

With the opening of your POC and the first rule is you must determine who is going to fix the problem and how it is going to be addressed for the individual or individuals affected by the deficient issue. Once you have made this decision and documented it in your plan, you can move on to the second part of correcting the deficient practice for your POC.

Next article will cover the second part of POC criteria. It should also be noted that the State of Texas presents an excellent training on the POC process at Texas POC Process.

Friday, October 21, 2016

The IPP (Individual Program Plan) is the core of active treatment, both formal and informal, for any Intermediate Care Facility (ICF). For the most part the IPP, developed at the annual staffing, details the needs of the person as projected over the next year. The goal of the IDTeam (Interdisciplinary Team) is to help the person develop an IPP that meets his or her needs and helps advance the person toward greater independence. In a perfect world that IPP would be reviewed and updated at the next annual staffing. Unfortunately, we do not live in a perfect world.

As you might imagine there is a lot that can go into an IPP. Depending on the abilities of the person served an IPP might cover basic areas such as getting up in the morning and getting dressed to taking a bus to work at a local job placement. The most important aspect of the IPP is that it has to be considered a "Changing Document". That is to say that it must be flexible, or alive, for the IDTeam and for the person it is designed to serve.

When I have said that an IPP must be a "Changing Document" to staff and others, I have sometimes seen a blank stare returned to me. It's the stare that says, "What?" I have had people ask me if this means we must change it monthly, or weekly. I have had others ask if we musth change it quarterly. The changing of an IPP is naturally dependent on several issues. Those issues that make the document a "Changing Document" are as follows:

1. The changing abilities of the person served - you may design an IPP to teach a person how to use a washing machine. The person may have an IPP designed to spend a year learning the washing machine; however, he or she masters the use of the washing machine in six months. At this point the IDTeam must consider that the individual's abilities have changed and that he or she now needs to progress to something else. It may be a move to the dryer, ironing, or even hanging up clothing. Whatever the IPP changes to will depend on the IDTeam's review and assessment of the person's abilities.

2. The changing of the person's environment - perhaps the individual has a job at a local restaurant. The IPP may address this with a service goal that says something like, "Johnny will attend to his part time job at the local restaurant each assigned day that he is on shift." Maybe for some unforeseen reason Johnny has a change in jobs. Maybe he stops working at the restaurant, maybe he gets a different job with a lawn company, or maybe he is fired. Whatever has happened, Johnny will need to have his IPP changed or modified to meet the changing environment that he has now found himself living in with regards to his IPP.

3. The changing of a person's needs - This could happen in several ways. Maybe the individual has never needed glasses, or hearing devices, or a walker before in his life. Suddenly, a change in his needs means that he now needs - just for example - glasses. Although the IPP has never addressed adaptive equipment before and the staffing may still be four months away, the change in the person's needs now supports a change in the IPP. Assessments must be completed and the IDTeam must determine how the IPP will address the new adaptive equipment.

5. A change in the person's behavior management needs - the fact of the matter is we all have "behaviors". Some behaviors are good, some are bad. Sometimes we may have no negative, or bad, behaviors at all and then for some reason we start having negative behaviors. When this happens, the IDTeam should follow a strict review process and implement the least, intrusive, corrective measure possible. For example, the individual might start being physically aggressive. The IPP would need to be modified to address those changes. This modification could include new informal goals, new formal goals, a behavior intervention plan of some sort, additional supervision or possibly psychiatric medications. Whatever intervention may come, the IPP should be modified to handle the changes and needs of the individual.

Now if you are paying close attention, you may have noticed that I skipped number four above. Number four is that mysterious factor - just as mysteriously it is missing in the list. It's what I like to refer to as the following:

4. Anything else mysterious, unforeseen or unexpected that the IDTeam may encounter - there are any number of possible factors here that can affect the unexpected or unforeseen. Maybe the person served suffers a loss of a parent - the IPP might need to be modified to incorporate counseling for the person. Maybe the person has some other life-changing event that the IDTeam has not considered. Whatever that unexpected or unforeseen "Anything Else" might be, the IPP should address it in some way. Hopefully, the unforeseen will be something as simple as a need to brush teeth better and not something major of life altering. However, if the unknown or unexpected happens, the IDTeam has a responsibility to remember that the IPP stands ready as a "Changing Document" to meet the person's new needs.

Monday, July 18, 2016

You read the headline and thought to yourself, "A surveyor would never interpret the standards would they?" The federal and state standards are clearly written, state exactly what they mean, and really should have no room for interpretation right? You would think that it would be clear and cut, but unfortunately that is not always the case.

Imagine you have been faced with an issue and had to take some action either as the QIDP or the Administrator. It really does not matter what the issue is, we can just assume it is any issue that could be considered a minor or major issue depending on how you look at it. You read the standards and it clearly says "If this happens, then you should do this." You look at the guidelines and decide what your organization is going to put in place to fix the problem. Done right? Well, maybe....

Two weeks later your annual survey shows up so naturally the action you have taken to correct a problem comes into the surveyor's sight. They ask the routine questions such as "What happened," "What action did you take?" "What was the result?" "Did notify XYZ?" You're able to answer all the surveyor's questions in order and with a reasonable answer....then it happens....out of the wild blue yonder the surveyor says, "Well did you do this?" You answer honestly and say, "Well no, I did not consider that and did not do that." .....Bam, the next thing you know the surveyor makes that statement, "Well, you know this is deficient practice and I'm going to have to cite this....."

If that has never happened to you, then congratulations! If on the other hand, you have faced the human surveyors, many who have been QIDPs before with their own ideas of what is right and what is wrong to do, then you have likely been subject to that area you did not consider. Whatever the case may be, many of us have found ourselves sitting there and thinking, "Well that's not in the tags...."

So, how can you handle these situations? I have on a few occasions been faced with this difficult situation. Now, do not misunderstand me, I completely understand where the surveyor is coming from and often agree that the question makes sense and it is something that the organization should have or might have considered doing, but ultimately it simply is not part of the standards. I have found it best to handle these situations in a couple of ways.

The first way I have handled them is to confront the surveyor directly. I might say, "Well, I see what you are saying, but we did not consider that because it was not in the standards and we did not feel we need to exceed standard requirements on this issue." That goes over well sometimes, and sometimes it goes over like a lead weight. If it does the later, then I usually indicate that I would like to talk to the program manager about the issue and do that.

The second way to handle these issues is to simply express your disagreement, or not, and wait for the tags to arrive. You can then assess the tags, discuss possible responses to the tags, and even consider arguing the tags through your state's dispute. Remember, in most cases the surveyors understand if you decide to follow your state's dispute route - that's what it's there for - disputes.

The final thing to consider is that after you've talked with the surveyor and expressed your views simply drop it. It's entirely possible that the surveyor will go back to the office, reconsider, or even be told by supervisors that they should not cite the particular situation. In those cases, and I have seen some, you will receive deficiencies that never mention the item the surveyor brought up. When this happens, it just confirms my faith that the surveyors are just as human and subject to errors as we are in the field.

Thursday, May 19, 2016

It several parts of Texas privacy during medication pass has become a focus issue in the ICF/IID homes during surveys. Recently one home was cited for giving medications at the dinging room table and the tag used was W130.

W130 does deal with privacy and specifically states "ensure privacy during treatment and care of personal needs". That seems straight forward enough, but if someone wants additional clarification, the guidelines for surveyors provides the following:
"Clients must be provided privacy during personal hygiene activities (e.g., toileting,
bathing, dressing) and during medical/nursing treatments that require exposure of one's
body.

People not involved in the care of the client should not be present without their consent
while they are being examined or treated.

Whenever possible, the facility should be sensitive to clients’ preferences for same sex
care in private situations. "

The above clarifies that privacy during certain activities is required. However, some facilities are receiving citations for giving oral medications in front of others. W130 was written because the medications were provided in front of others. It could be argued that the section of the guideline stating that "People not involved in the care of the client should not be present without their consent while they are being examined or treated" means that a privacy should be maintained during oral medication pass as well. However, it would be more likely that this statement is referring to an examine or treatment with a physician or nurse that requires "exposure of one's body" in some specific way such as removing a shirt, pants, etc. It could also be assumed that the "treated" part of this guideline also refers to when there is "exposure of one's body" as stated in the previous sentence. The case could be made that treated also refers to an oral medication pass, but I think this point could be argued on the basis that there was no "exposure of one's body".

Looking at the guidelines, it is hard to equate taking a pill with "medical/nursing treatments that require exposure of one's body". The only example noted in the deficient practice was that the individual took his medications in front of others. It was not noted whether he objected or wanted the other people around or not.

Had the facility been prepared for an Informal Dispute Resolution (IDR) in Texas, it might have been the time to move forward with one. The use of W130 for an oral medication seems to be a stretch at best, but had it been connected to a discussion of the medications, then it might have been clear what the problem was in this instance. For example, if the individual took a specific medication for cancer treatment, then his privacy would have been violated had staff discussed what the medication was used for in front of others at the table. The final result was that the facility administration really had no idea what was done wrong, but wrote a Plan of Correction (POC) all the same and submitted it for review. The facility will likely clear a follow up visit and move forward. It would be logical to assume that if this trend continues, private providers are going to be forced to strongly consider the IDR process.

Friday, April 29, 2016

Provider letter 16-13 ( Information Letter No. 16-13 — Supported Decision-MakingAgreement Act ) introduced the Supported Decision Maker
to just about every program in the state of Texas as an alternative to
guardianship. Unfortunately, for the
ICF/IID programs, it ultimately presents more concerns than it does supports
and may really be a problem for ICF/IID use.

The act presents a “Supported Decision Maker” into the
equation for ICF/IID, or a SDM.It
should not be confused with a “Surrogate Decision Maker” from the Surrogate Program
that is also known as an “SDM”.This act
is entirely separate from the surrogate program.It does present some potential concerns when
dealing with the surrogate program for individuals who have always depended on
that program.

A quick read through the role of an SDM will indicate that
the SDM is to gather information and to communicate the individual’s “life
decisions”.This is all done after the
individual (the client in the ICF/IID) signs a supported decision-making
agreement with the person who will serve as the SDM.The
SDM does not make the decisions, but only helps the person make the decisions
and then communicates the person’s decision to the appropriate person(s).It sounds all straight forward in a basic
reading.

After reading over the entire act, the sample agreement, and
the responsibilities of the SDM, there are several concerns that may need to be
addressed by the next legislative session:

1. This act does nothing to resolve the “waiting”
period faced by ICF/IID providers when it comes to the Surrogate Decision
Making Program.The program often can
take months to complete and obtain a legal consent for things needed
immediately such as psychotropic medications.The facility and IDTeam usually has no choice except to give the
medications while consent through the Surrogate Program is being sought.A better use for the SDM would have been to have
this person make a decision pending a Surrogate Decision Making Committee’s
review of the decision, but that application would only apply to ICF/IID programs
that use the Surrogate Program.

2. This act allows 14 year olds to sign the
agreement as a witness.Since a 14 year
old is not a legal adult, there can and will likely be problems with those signatures
being considered “legal” witnesses to the agreement.

3. The act assumes the person with the disability
requires assistance with making decisions without any assessment to determine
if that individual needs assistance.Further, if the individual needs assistance in making decisions, then
who decides the individual with disabilities has the ability to understand and
sign the agreement to obtain an SDM?

4. Some providers may see this as an avenue to avoid
the Surrogate Decision Making Program’s long, and often paperwork intensive,
procedures.If a facility does decide to
use the SDM and avoids the Surrogate program, what grounds will a surveyor have
to cite the facility regarding consents?Will the surveyor refer to prior Surrogate use?The new law creates some confusion here since
the SDM presents information and communicates the person’s decision.If the decision is “I want to take
Risperdal,” and that is communicated, then in theory the IDTeam could accept
this as consent without using the Surrogate Program.Again, this is going to create issues for the
surveyor and the provider as to how to defend their cases for or against
deficient practice.

5. The act also gives no consideration to the level
of disability.It simply “assumes” that
a few questions can be presented to anyone with disabilities and he or she will
decide they “want” an SDM.Based on the
wording, a person with Profound Intellectual Disabilities who simply nods his
or her head at the right time during questions, could sign the agreement.The SDM could then present that individual’s
“decision” to the rest of the IDTeam based on whatever efficient level of
communication the SDM has with the individual.There would be no way of telling if the person really wanted the SDM or
really made the decision as presented.

6. The act does not give any consideration to other
assessments.For example, if a person
has been using the Surrogate Program for consent for psychotropic medications –
does the assessment from the previous Surrogate Application mean the person can
not obtain a Supportive Decision Maker?If the person does obtain a SDM, what grounds does that leave for surveyors
who believe the person can not give consent?

7. Since anyone can be an SDM in this program, it
means that Administrators, QIDPs, Managers and even direct care staff could
sign the agreement.For that matter, a
person’s physician could sign the agreement, present the information to the
person, and then communicate that person’s decision to the facility regarding
surgery, medications, etc.This would
then mean that consent is assumed by the person’s decision.

Overall, the Supportive Decision Making Act can likely be a
benefit to many programs in the state.It has been applied to the ICF/IID programs, but probably should not
have been.It will create confusion and
in some cases such as situation when a surveyor writes deficient practice
pertaining to consents, the SDM may be the fall back defense in an Informal
Dispute Resolution (IDR) or even a lawsuit presented by the provider or the
SDM.In theory, the provider could
present that the SDM provided the individual’s decision regarding an issue and
that the decision was then accepted as consent.In such a case as this, should it reach a
legal level, it would be up to a court to determine if the person had ever been
“deemed incompetent in a court of law,” and usually if they have not, then the
court considers that person competent to make his or her own decisions.